4. Rosenman KD, Gardiner JC, Wang J, Biddle J, Hogan A, Reilly MJ, etal. Why most workers with occupational repetitive trauma do not file forworkers’ compensation. J Occup Environ Med 2000;42:25–34.

5. Shannon HS, Lowe GS. How many injured workers do not fileclaims for workers’ compensation benefits? Am J Ind Med 2002;42:467–473.

6. Bianchini KJ, Curtis KL, Greve KW. Compensation and malingeringin traumatic brain injury: a dose-response relationship? Clin Neuro-psychol 2006;20:831–847.

7. Mittenberg W, Patton C, Canyock EM, Condit DC. Base rates ofmalingering and symptom exaggeration. J Clin Exp Neuropsychol2002;24:1094–1102.

8. Boden LI. Workers’ compensation in the United States: high costs,low benefits. Annu Rev Public Health 1995;16:189–218.

9. Hunt HA. Benefit adequacy in state workers’ compensation pro-grams. Soc Secur Bull 2003;65:24–30.

10. Bellamy R. Compensation neurosis: financial reward for illness asnocebo. Clin Orthop Relat Res 1997:94–106.

11. Cornes P, Bochel HM, Aitken RC. Rehabilitation and return towork of employers’ liability claimants. Int J Rehabil Res 1986;9:119 –128.

12. Loisel P, Durand MJ, Diallo B, Vachon B, Charpentier N, Labelle J.From evidence to community practice in work rehabilitation: theQuebec experience. Clin J Pain 2003;19:105–113.

13. Wickizer TM, Franklin GM, Mootz RD, Fulton-Kehoe D, Plaeger-Brockway R, Drylie D, et al. A community-wide intervention toimprove outcomes and reduce disability among injured workers inWashington State. Milbank Q 2004;82:547–567.

14. Dembe AE. The medical detection of simulated occupational inju-ries: a historical and social analysis. Int J Health Serv 1998;28:227–239.

In Reply:We would like to thank Sears et al. for their

comments regarding our study “A Decision-AnalysisModel to Diagnose Feigned Hand Weakness.”1 Theircomments will help us clarify the intent of our studyand in doing so we will demonstrate that our funda-mental goals are similar. First, we will address 3important points that were brought up regarding ourarticle, and then we will discuss how our study mayserve as an important component within the type ofreform suggested by Sears et al.

1. “There is little if any credible research addressingrates of feigned or exaggerated symptoms in theWC [workers’ compensation] population that isgeneralizable to the universe of WC claims or tothe federal subset.”

We agree that it may be challenging to pre-cisely estimate the true prevalence of malinger-ing within the WC system. However, there is alarge body of literature that unequivocally showscompensation status is correlated with poorerclinical outcome.2–19 In fact, a meta-analysispublished in the Journal of the American MedicalAssociation states that “compensation status isassociated with poor outcome after surgery. Thiseffect is significant, clinically important, and

consistent.”20 Specifically, data from 129 studiescovering 20,498 patients found the odds ratio ofan unsatisfactory outcome in compensated pa-tients to be 3.79 (95% confidence interval, 3.28-4.37).20 There is another body of literature dem-onstrating that compensation status is correlatedwith higher costs of providing medical care andlonger periods of recovery.19,21–23 Furthermore,there is evidence that shows higher WC benefitresults in more benefit claims.19,24,25 For exam-ple, after a “rigorous synthesis of the best avail-able theory and empirical evidence on the effectof wage-replacement benefits on the incidenceand duration of claims under WC programs,”John D. Loeser, MD, of the University of Wash-ington (Seattle, WA), concludes that “the extanteconomic studies imply a positive relationshipbetween the level of wage replacement and boththe incidence and the duration of WC disabilityclaims.”24 Specifically, this study estimates thatincreasing claim benefits by 10% correlates witha 1% to 11% increase in the frequency of WCclaims and a 2% to 11% increase in duration perclaim.24 Based on this extensive body of litera-ture, our statement that feigned hand weakness isan important problem can hardly be characterizedas “unsubstantiated and misleading.”

Regardless, the intent of our study was not toperform the monumental task of quantifying theexact statistics of malingering within the WC sys-tem or to make “unsubstantiated and misleading”claims. Instead, the specific purpose of our articlewas to “review the current literature on diagnosingfeigned hand weakness and propose an efficientdiagnostic scheme,” which may be useful to physi-cians when clinical judgment suggests malingering.

In stating that physicians have a responsibilityto detect malingering so that our limited re-sources can be allocated to patients who trulyneed them, we certainly were not trying to “re-inforce adversarial provider-patient relationshipsand biased views toward certain patients.” Incontrast, we want to ensure that physicians do notjump to the conclusion of feigned hand weaknessbased on subjective clinical suspicion alone. Ourproposed comprehensive diagnostic scheme willhelp physicians when there is subjective clinicalsuspicion to follow up with objective tests. Itseems quite obvious to us that introducing objec-tivity to a diagnosis that is largely subjectiveshould undo any existing biases that individualphysicians may hold toward “certain patients.”

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2. “Any patient they evaluate and for whom they arewilling to bill the WC system is a ‘true patient,’and one to whom they owe a clinical duty.”

We agree that any patient for whom we “billthe WC system” is a true patient to whom we oweclinical duty. In fact, we believe that any patientfor whom we do not bill the WC system is also atrue patient who deserves our full clinical duty.But, our point in using terms such as “true pa-tient” and “malingerers” was not to stratify pa-tients so that we can care for the former andignore the latter. Instead, we defined these termsfor the purpose of our research study so that wecould communicate the results of our literaturesearch and propose a diagnostic scheme.

3. “Focusing on the detection of exaggerated symp-toms will not eliminate the costs of delayed re-turn to work or reduce costs due to litigation andconflict.”

We are committed to the old American adagethat it is better to free a criminal rather than punishan innocent man, as evidenced by our statement “indeveloping diagnostic tests, we must remember thatit is better to miss an insincere individual than toclassify a sincere patient as insincere.”1 In our ar-ticle, we dedicated a section (“Critical Evaluation ofDiagnostic Tests”)1 to discussion of the concepts ofsensitivity, specificity, false-positive results, andfalse-negative results to reinforce the observationthat no single test is perfect. This is why we pro-posed a diagnostic scheme under the section“Choosing Between Tests,”1 which combines theavailable tests in a statistically rational manner withthe goal of minimizing the number of people whomay be falsely classified as malingerers. Therefore,we are not placing undue importance upon “focus-ing on the detection of exaggerated symptoms” as aclinical dogma. Our proposition is simple: We be-lieve all patients must be treated equally, and whenmalingering is suspected on clinical exam, physi-cians must have an objective standard that they canuse to investigate further.

Our goal with this study was not to address the“costs due to litigation and conflict” in the WCsystem. However, society places the responsibil-ity of diagnosing illness on physicians. It is thephysician who has to sign off on legal documentsattesting that a patient can or cannot perform hisor her job. Therefore, when a physician suspectsmalingering, he or she must have objectivemeans of investigating it. This is no differentfrom when a physician suspects bacterial menin-

gitis and decides to obtain a spinal fluid culture.We did not recommend that patients who fail thetests we described should not be given their com-pensation. We recommended that “future re-search should focus on developing objective di-agnostic tests so that we can detect fraud withoutpenalizing sincere patients.”1 We acknowledgedthat there need to be consensus meetings of ex-perts to develop more specific criteria and thatmore research should be conducted to developingbetter objective tests. We even recommended twopossible tests—electromyography and sonomyo-graphy—that interested readers could pursue.

The WC system should be reformed to offer acomprehensive and nonadversarial environment forpatients. Reform must be comprehensive becauserecovery involves psychosocial and emotional as-pects in addition to purely physical improvement.26

Furthermore, reform must make the system nonad-versarial so patients can discuss their physical, social,and emotional issues freely without having to provetheir disabilities. The pilot programs of Quebec andWashington are positive steps because they makeresources available for such nonphysical aspects andguard against evaluating patients from physicalbenchmarks alone. Such changes will inevitably im-prove conditions for the vast majority of patients andmay reduce costs as well. However, it will not obvi-ate the importance of our study, “A Decision-Anal-ysis Model to Diagnose Feigned Hand Weakness.”1

This is because resources will still be limited, andsociety will still place the responsibility of detectingfeigned hand weakness on physicians. Establishedobjective standards will aid physicians in fulfillingthis responsibility impartially. We hope that our ar-ticle sparks an interest for future research in devel-oping consensus criteria to detect feigned hand weak-ness and creating better objective tests.

Ahmer K Ghori, BAUniversity of Michigan School of Medicine

Ann Arbor, MI

Kevin C Chung, MDSection of Plastic Surgery

Department of SurgeryThe University of Michigan Health System

Ann Arbor, MI

doi:10.1016/j.jhsa.2008.02.024

REFERENCES

1. Ghori AK, Chung KC. A decision-analysis model to diagnosefeigned hand weakness. J Hand Surg 2007;32A:1638–1643.

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2. Beals RK. Compensation and recovery from injury. West J Med1984;140:233–237.

3. Bosacco SJ, Berman AT, Bosacco DN, Levenberg RJ. Results oflumbar disk surgery in a city compensation population. Orthopedics1995;18:351–355.

4. Browne CD, Nolan BM, Faithfull DK. Occupational repetition straininjuries. Guidelines for diagnosis and management. Med J Aust1984;140:329–332.

5. Burdorf A, Jansen JP. Predicting the long term course of low backpain and its consequences for sickness absence and associated workdisability. Occup Environ Med 2006;63:522–529.

6. Chibnall JT, Tait RC. Confirmatory factor analysis of the PainCatastrophizing Scale in African American and Caucasian workers’compensation claimants with low back injuries. Pain 2005;113:369–375.

7. Derebery VJ, Tullis WH. Delayed recovery in the patient with awork compensable injury. J Occup Med 1983;25:829–835.

8. Frieman BG, Fenlin JM Jr. Anterior acromioplasty: effect of litiga-tion and workers’ compensation. J Shoulder Elbow Surg 1995;4:175–181.

9. Frymoyer JW. Predicting disability from low back pain. Clin OrthopRelat Res 1992;279:101–109.

10. Frymoyer JW, Rosen JC, Clements J, Pope MH. Psychologicfactors in low-back-pain disability. Clin Orthop Relat Res 1985;195:178 –184.

11. Greenough CG, Taylor LJ, Fraser RD. Anterior lumbar fusion. Acomparison of noncompensation patients with compensation pa-tients. Clin Orthop Relat Res 1994;300:30–37.

12. Guck TP, Meilman PW, Skultety FM, Dowd ET. Prediction oflong-term outcome of multidisciplinary pain treatment. Arch PhysMed Rehabil 1986;67:293–296.

13. Hadler NM. Cumulative trauma disorders. An iatrogenic concept. JOccup Med 1990;32:38–41.

14. Hammonds W, Brena SF, Unikel IP. Compensation for work-relatedinjuries and rehabilitation of patients with chronic pain. South MedJ 1978;71:664–665.

15. Krusen EM, Ford DE. Compensation factor in low back injuries.J Am Med Assoc 1958;166:1128–1133.

16. Leavitt F. Predicting disability time using formal low back painmeasurement: the Low Back Pain Simulation Scale. J PsychosomRes 1991;35:599–607.

17. Misamore GW, Ziegler DW, Rushton JL II. Repair of the rotatorcuff. A comparison of results in two populations of patients. J BoneJoint Surg 1995;77A:1335–1339.

18. Trief P, Stein N. Pending litigation and rehabilitation outcome ofchronic back pain. Arch Phys Med Rehabil 1985;66:95–99.

19. Bellamy R. Compensation neurosis: financial reward for illness asnocebo. Clin Orthop Relat Res 1997;336:94–106.

20. Harris I, Mulford J, Solomon M, van Gelder JM, Young J. Associ-ation between compensation status and outcome after surgery: ameta-analysis. JAMA 2005;293:1644–1652.

21. Industry MDoLa. Report to the legislature on health care costs andcost containment in Minnesota workers’ compensation. Minnesotahealth care costs: workers’ compensation compared to non-workers’compensation. St Paul, MN: Minnesota Department of Labor andIndustry, 1990:13–27.

22. Industry MDoLa. Report to the legislature on health care costs andcost containment in Minnesota workers’ compensation. Conclusionsfrom the empirical research on Minnesota’s workers’ compensationmedical costs. St Paul, MN: Minnesota Department of Labor andIndustry, 1990:53–55.

23. Durbin DL, Corro D. Workers compensation price v. quantity:implications for a medical price index. Hoboken, NJ: National Coun-cil on Compensation Insurance, 1993:1–40.

24. Loeser JD, Henderlite SE, Conrad DA. Incentive effects of workers’compensation benefits: a literature synthesis. Med Care Res Rev1995;52:34–59.

25. Worrall JD, Appel DT. The wage replacement rate and benefitutilization in workers’ compensation insurance. J Risk Insurance1982;49:361–369.

26. Jane D, William HT. Prevention of delayed recovery and disabilityof work-related upper extremity disorders. Clin Occup Environ Med2006;5:235–247.

Radial Longitudinal Deficiency

To the Editor:The article by Peterson, McCarroll, and James1 pro-

vided several interesting perspectives related to radiallongitudinal deficiency (radial aplasia of the upperlimb) and late treatment. In this article, the authorsreport on 9 patients (13 procedures) directed at ulnarlengthening in limbs with Bayne types III/IV with pre-vious treatment of radial deficiency. The authors hon-estly and quite clearly reported the many difficulties andcomplications associated with ulnar lengthening usingthe Ilizarov system. They reported that all patients hada pin track infection and in 3 cases the infection led toremoval of the fixator and loss of alignment or failure ofunion at the osteotomy site. Six of the 13 lengtheningprocedures had increased elbow stiffness or finger de-formity associated with the procedure. The averagetime in the frame was more than 3 months, and time toconsolidation (presumably excluding those not united)was nearly 6 months (range, 12–25 weeks). Despite the

extensive effort involved, however, the average in-crease in length of the forearm was only 4.4 cm (max-imum, 8.0 cm). One presumes, based on patient age(9–17 years), that the ulna physis had closed and thatfurther ulna growth would not occur.

My personal experience2 with ulna lengtheningfor radial aplasia in 17 patients, including 7 patientsless than 9 years old with a Kessler frame and theremaining 10 over the age of 10 with a modifiedIlizarov frame (distal Ace–Colles half-frame withproximal full-circle frame), mirrors the authors’ ex-perience. The case series and case examples reportedhad similar challenges related to pin sites and elbowcontractures, and to prevent wrist deformity theframe was extended across to the carpus. With theexception of 1 patient with bilateral radial dysplasiawith very short limbs (Bayne IV), for whom thelengthening allowed the hands to reach the face foreating and to reach the head in part for grooming, my

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